I’ve been to Canada, but I’ve never been to Ottawa. I suppose, as the capital of Canada, it makes sense they’d be enamored with rules and rule-making. Regardless, it still seems they have a disproportionate burden of rules, for better or worse.
This latest publication describes the “Ottawa Chest Pain Cardiac Monitoring Rule”, which aims to diminish resource utilization in the setting of chest pain in the Emergency Department. These authors posit the majority of chest pain patients presenting to the ED are placed on cardiac monitoring in the interests of detecting a life-threatening malignant arrhythmia, despite such being a rare occurrence. Furthermore, the literature regarding alert fatigue demonstrates greater than 99% of monitor alarms are erroneous and typically ignored.
Using a 796 patients sample of chest pain patients receiving cardiac monitoring, these authors validate their previously described rule for avoiding cardiac monitoring: chest pain free and normal or non-specific ECG changes. In this sample, 284 patients met these criteria, and none of them suffered an arrhythmia requiring intervention.
While this represents 100% sensitivity for their rule, as a resource utilization intervention, there is obviously room for improvement. Of patients not meeting their rule, only 2.9% of this remainder suffered an arrhythmia – mostly just atrial fibrillation requiring pharmacologic rate or rhythm control. These criteria probably ought be considered just a minimum standard, and there is plenty of room for additional exclusion.
Anecdotally, not only do most of our chest pain patients in my practice not receive monitoring – many receive their entire work-up in the waiting room!
“Prospective validation of a clinical decision rule to identify patients presenting to the emergency department with chest pain who can safely be removed from cardiac monitoring”